Quarterly Cost Share Technical Assistance Request for Payment

District *

Date * +

PY2021 Master Agreement Contract Number

Period Covered by this request (select all that apply) *

1st Quarter {July 1, 2020 - September 30, 2020}

2nd Quarter {October 1, 2020 - December 31, 2020}

3rd Quarter {January 1, 2021 - March 31, 2021}

4th Quarter {April 1, 2021 - June 30, 2021}

Yearly {July 1, 2020 - June 30, 2021}

Submitted By: *

Title *

District Employee

County Finance

Email address *

Total Salary/Benefits
(Do not include "$" or "," (comma)
*

Salary to be Paid To: *

County

District

FID#

Total Operating Expenses
(Do not include "$" or "," (comma)
*

Operating to be Paid To: *

County

District

FID# (if different from above)

Upload County budget (to show the salary and expenses paid out to your district) *

Comments or Additional Information:

Please reimburse this amount:

$0.00

Please email Paula.Day@ncagr.gov or call 919-707-3786 with any questions or concerns.

Signature *

clear